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INTRODUCTION

Stroke is relatively uncommon in women of childbearing age. The occurrence of stroke during pregnancy has the potential for catastrophic maternal and fetal complications. Stroke is defined as an acute neurological insult resulting from obstruction or rupture within the cerebral vascular system not caused by tumor or trauma. Stroke, also known as cerebrovascular accident (CVA), is based on a hemorrhagic or ischemic etiology. Hemorrhagic stroke includes intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Commonly, hemorrhagic strokes are the result of a structural disruption of cerebral vasculature and are associated with malignant or uncontrolled hypertension, arteriovenous malformation (AVM) rupture, or cerebral aneurysm rupture. Ischemic CVA develops after hypoperfusion or disruption of cerebral blood flow and leads to focal vascular obstruction. Most ischemic strokes result from arterial occlusion. Less frequently, ischemic events are secondary to venous thrombosis, paradoxical embolus, or cardioembolism. Systemic hypoperfusion from peripartum cardiomyopathy, arterial hypotension, cardiac arrhythmias, and cervical artery dissection of carotid or vertebral arteries may also lead to reduced cerebral perfusion and precipitate an ischemic etiology.1 Transient ischemic attacks are temporary disruptions in blood flow with symptoms lasting less than 24 hours but portend an increased lifetime risk of CVA.2

Normal maternal adaptations may alter the incidence and outcome of CVA that occurs during pregnancy. Although controversial, the increased cardiac output, venous stasis, and endothelial permeability in addition to a hypercoagulable state likely affect thrombotic and hemorrhagic CVA. It is biologically plausible that hormonal-mediated changes in vascular organization, thrombotic propensity, and exacerbation of hypertension disorders during pregnancy can predispose women for stroke development.3

A standard approach to management in pregnant women is difficult, as insufficient evidence exists to guide a consensus for evaluation and treatment of stroke in this important population. This chapter will review the clinical presentation, establish a diagnostic approach, and suggest management of CVA in pregnancy.

EPIDEMIOLOGY

Incidence

A US population-based study estimates 8.9% of ischemic strokes and 22.6% of hemorrhagic strokes were associated with pregnancy in younger women.3 The incidence of stroke in pregnancy is estimated at 11 to 34 per 100,000 deliveries.4,5 Increasing maternal pre-pregnancy body mass index, chronic cardiovascular conditions in childbearing age women, increased consumption of high-fat diets, and older parturients will likely promote a higher prevalence in the future.

Over a 10-year period, Kissela et al. showed an increase in frequency of total stroke cases occurring in the young adult population ages 15 to 44 years from 13% to 19%,6 which paralleled the increase in hospitalizations for pregnancy-related stroke events by 47% antenatally and 83% postnatally.7 The increase in postpartum admissions was mostly attributed to hypertensive disorders and cardiac disease, which further highlights that the significant role of concurrent cardiovascular disease (CVD) has on the incidence of pregnancy-related CVA.